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What’s Important?

  1. When using any type of skin lightener, it can take 12–16 weeks to see a visible decrease in skin pigmentation.

  2. Fatty acids in moisturizers can affect tyrosinase activity.

  3. Hydroquinone alone or in combination with a topical steroid and retinoid have the best efficacy.

  4. Triple combination creams containing a tyrosinase inhibitor, a retinoid, and a corticosteroid remain the best topical skincare product to lighten skin.

  5. Coenzyme Q10 is an antioxidant, increases ATP production, and inhibits tyrosinase activity by affecting gene transcription.

What’s New?

  1. Oral tranexamic acid has been shown to be safe and very effective for melasma.

  2. Hydroquinone is no longer allowed in cosmetic products in the United States.

What’s Coming?

  1. Studies and clinical experience will evaluate the efficacy, dosing, and optimal protocols for the use of tranexamic acid intradermally or with microneedling.

  2. More studies and clinical experience on oral tranexamic acid are needed to determine the most effective treatment and maintenance protocols and relapse rates.

  3. More studies on the use of cysteamine in pigmentation disorders and the mechanism by which it inhibits melanin formation are needed.

  4. Studies on the efficacy of oral melatonin will shed light on melatonin’s role in pigment production.

  5. New ingredients to replace hydroquinone and its derivatives are being developed.

  6. Glutathione is not recommended until stable topical forms that can penetrate the skin have been developed; oral forms have poor bioavailability; and IV forms need far more studies evaluating safety, efficacy, and optimal dosing.

Dark spots on the skin, whether they are solar lentigos, postinflammatory hyperpigmentation, or melasma, are a source of embarrassment and stress for many cosmetic patients. (The causes of dyschromia are discussed in Chapter 20, Skin Pigmentation Disorders.) Hyperpigmentation is difficult to treat because sun, heat, blue light, stress, hormones, and other factors that are difficult to avoid contribute to melanin development. Teaching patients the appropriate lifestyle habits for preventing pigmentation and how to use a skincare routine to erase unwanted dark spots is discussed in Chapter 14, Uneven Skin Tone. This chapter will review the ingredients in skincare products that lighten dark spots on the skin to give an even complexion. These ingredients are typically used in combination and rarely alone. A triple combination cream (TCC) is the most commonly used type of skincare product to lighten dark spots on the skin.

Melanin synthesis within melanosomes and their distribution to keratinocytes within the epidermal melanin unit determines skin pigmentation. Hyperpigmentation occurs when this system goes awry (see Chapter 20). Dark spots and hyperpigmented patches that lead to an uneven skin tone are unacceptable to cosmetic patients. For this reason, hundreds of products on the market are touted as “lightening creams” or “brightening creams.” Although there are many product choices available, the number of effective agents to treat hyperpigmentation disorders is relatively small. Further, all of these agents require 3 to 4 months of use for improvement to be seen. Combining ...

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